Development and Implementation of an Evidence-Based Guideline for Spinal Cord Injury/Disorder Patients Requiring Colonoscopy

Practice Problem: Colorectal cancer is one of the leading causes of preventable cancer death in the United States. Spinal cord injury/disorder (SCI/D) patients present with unique challenges for maximizing bowel prep and successful attainment of screening and therapeutic colonoscopy procedures. Current practice for bowel prep regimen does not take into consideration the specific needs of the SCI/D population resulting in significant patient dissatisfaction. PICOT: The PICOT question that guided this project was in adult patients with spinal cord injuries/disorders requiring colonoscopy (P), how does the development and implementation of evidence-based guideline for the care of the spinal cord injury/disorder patient requiring colonoscopy (I) compared to usual practice (C) affect the rate of first attempt successful colonoscopy procedure completion (O) within eight weeks (T). Evidence: SCI/D patients resulting neurogenic bowel increases difficulty with standard bowel prep tolerance. Quality bowel preparation is required for successful colonoscopy with inadequate bowel preparations present in 20-25% of all colonoscopies (Johnson et al., 2014). Evidence supports a clinical guideline for bowel preparation adapted to the needs of the SCI/D population. Intervention: Development and implementation of an SCI/D bowel prep guideline enhanced clinical decision support and evidence-based tools for improved bowel prep with initial attempt. Outcome: The rate of first-time colonoscopies for patients with SCI/D with the guideline improved by over 214% over pre-guideline time. Conclusion: The evidenced-based guideline reinforced clinical practice for the SCI/D population related to their unique requirements. Clinically significant improvement was noted in successful bowel prep completion, first attempt colonoscopy completion, improved access to the endoscopy suite, and reduced length of stay. All combined improved both patient and provider satisfaction with the evidence-based practice change.

688 Cancellation Rate of Prostate Template Biopsy: Are There Any Merits to Implementing Pre-Operative Bowel Preparations?

Introduction The aim of this quality improvement project was to analyse the cancellation rates of the template biopsy done at the George Eliot Hospital. The focus was mainly on those due to poor bowel prep whereby manual evacuations have failed. Locally we have sometimes noted the failure rate of transperineal prostate biopsy as a result of the poor quality of the ultrasound due to inadequately evacuated rectum. Unfortunately, there are very limited studies which have looked into this issue hence the significance of this problem is not universally acknowledged. Method Retrospective review of all the template biopsies that were planned from April 2019 to April 2020 using the operation notes and local theatre management software. Results There was a total of 105 planned template biopsies from April 2019 to April 2020. 72 cases were attempted and within this, 7 of these cases required manual evacuations in which 3 resulted in abandonment of procedure. There were 33 cases which were cancelled due various other reasons. Conclusions The results showed that the failure rates due to poor bowel prep were not significant (4%). Based on these findings we have decided not to proceed with the implementation of pre-operative bowel prep with phosphate enema as we felt that the potential benefits were not enough for it be initiated as a routine practice. We aim to address the other reasons identified for cancellations.

P100 Higher yield of serrated and adenomatous dysplasia detected with chromoendoscopy when compared with high-definition in patients with Primary Sclerosing Cholangitis and Inflammatory colitis

Background There is an increased risk of colorectal dysplasia/cancer in patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD); cumulative risk of 14% at 5 years and 17% at 10 years. SCENIC (2015) consensus guidelines recommend surveillance with chromoendoscopy (CE) and use of a high definition (HD) scope with white light colonoscopy. We aimed to assess the value of CE and HD scope in detection of dysplasia in PSC-IBD. Methods We analysed all colonoscopic surveillance performed for PSC-IBD between 2010–2020 at Oxford University Hospitals (n=422 procedures). Continuous variables were assessed by Kruskal-Wallis (three groups) and categorical variables by Chi-square test. Repeat measurements were accounted for by multilevel regression models with individual colonoscopies nested within patients. Multilevel ordinal logistic regression was used for assessment of bowel prep. Outcomes were adjusted for confounding variables (adj). Results 359 colonoscopies were analysed in 91 patients with PSC-IBD (69/422 were excluded as prior dysplasia detected). CE and HD scope use increased in frequency over the 10-year period (p=0.02). HD were rarely used in those with bowel preparation deemed inadequate (p<0.001), but there was no association between CE and bowel prep quality. Dysplasia detection (adenomatous and serrated lesions) was higher with CE compared with white light examination; 14% vs 3% (p<0.001), and after adjusting for confounders (p<0.009) and use of HD scope (p<0.01), OR 5.02 (CI 1.43–17.7). Dysplasia detection was higher with HD compared with standard definition (SD); 14% vs 6% (p<0.04), but was non-significant after adjusting for confounders, OR 1.93 (CI 0.69–5.4). Dysplasia was more likely to be found on targeted than random colonic biopsies (p<0.001). CE increased detection of serrated lesions (9% vs 2% (p=0.06) OR 3.5 adj) and more so adenomatous dysplasia (6% vs 1% (p=0.03) OR 12 adj) compared to white light. HD increased detection of serrated lesions (9% vs 3.5% (p=0.04) OR 2 adj) but not adenomatous dysplasia (6% vs 2.5% (p=0.19) compared to SD. (Table 1) Conclusion CE is superior to HD and SD white light examination for dysplasia detection in PSC-IBD after accounting for confounders and performed better for adenomatous than serrated lesions.

A pilot study for using high-volume colon irrigation bowel preparation for colon capsule endoscopy shows feasibility of adequate bowel prep with high patient satisfaction

A feasibility study was performed to test a bowel preparation (BP) method that would improve patients’ experience of colon capsule endoscope (CCE) while retaining clinical adequacy. Specifically, the use of high-volume colon irrigation with the Hygieacare® System, HygiPrep™, was tested in conjunction with Medtronic’s PillCam COLON 2 Capsule. This prospective, single-center, and IRB-approved study evaluated HygiPrep use prior to the PillCam COLON 2 procedure instead of the standard split-polyethylene glycol-electrolyte (PEG) oral prep. The study was performed at Austin Gastroenterology (Austin, TX), and all capsule video files were forwarded to a Central Reader to evaluate and compile a study report. Six of the seven (86%) subjects completed both the HygiPrep and PillCam COLON 2 exams and were graded as excellent, good, or adequate by the Central Reader. Patients’ feedback reported positive satisfaction scores for both the HygiPrep and the PillCam COLON 2 procedures. These results support our hypothesis that HygiPrep was as effective as Split-PEG BP. We suggest that the HygiPrep, is a suitable BP for CCE, providing adequate BP and high patient satisfaction.

New Ultra Low Volume Bowel Preparation and Overview of Existing Bowel Preparations

Background: Adequate bowel cleansing is essential in achieving a good quality colonoscopy. However, one of the barriers to achieving high-quality bowel cleansing is the patient's tolerability. Different bowel preparations have been developed to improve tolerability while maintaining adequate bowel cleansing. Objectives: We aim to explore the pros and cons of commonly used bowel preparations, particularly highlighting the new ultra-low volume bowel preparation. Methods:: Extensive literature search was carried out on various databases to evaluate the effectiveness and side effects of different bowel cleansing agents, including findings of recent clinical trials on ultra-low bowel preparation. Results:: Polyethylene glycol (PEG) has been commonly used as a bowel prep. Due to its high volume required to ingest to achieve an adequate effect, it has been combined with various adjuncts to reduce the volume to make it more tolerable. Magnesium and phosphate-based preps can achieve low volume, but they can be associated with multiple side effects, mainly electrolyte disturbances. Ultra low volume prep (NER1006) was achieved by combing PEG with ascorbic acid, and its efficacy and side effects were demonstrated in three noninferiority studies. Conclusion: It is important to consider patient preferences, co-morbidities and tolerability, and efficacy and side effect profiles when choosing bowel prep for patients undergoing colonoscopy. New ultra-low bowel prep showed promising results in initial clinical trials, but further real-world post-marketing data will inform its value in clinical practice.